IMPACTO AMBIENTAL 190,191,192

In order to move forwards and improve, PD practice must consider a set of challenges;

most of which stem from attempting to reconcile theory and previous experience with current and emerging issues concerning the changing socio-political landscape, the development and application of new technologies, and the complexities of the contexts of use. The present review points to a non-exhaustive list of challenges which relate to aspects external or internal to the design process; and, since user participation is at the very core of PD, a complementary review looks particularly at issues related to, or involving the participation of, people within design practice.

External to the PD Process

Bowen et al. (2013) found that healthcare staff participating in design interventions recognised the complexity of hospitals as a factor contributing to making changes difficult and lengthy. This view is shared by Pilemalm & Timpka’s analysis which outlines the heterogenous characteristic of health organisations that, additionally, have

‘multiple hierarchical levels’ (Pilemalm & Timpka, 2008). Bringing together

professionals working within these organisations to come to a face-to-face activity is

79 rather hard, since staff are mobile, widespread geographically and frequently

unavailable (Jun et al., 2017).

In face of this reality, aligning and complying with organisational/local and national standards is problematic; as is managing the erratic participation of staff while not losing sight of timelines and technical/external project requirements and constraints, within a stepwise implementation process (Simonsen & Hertzum, 2012).

Investment in human capital (i.e. interdisciplinary teams, including designers, capable of conducting participatory research) will be critical to future PD in healthcare. Teams will need to be able to enact and sustain participatory changes within institutions;

otherwise bringing about change will always be disruptive to the work practice (Balka, 2013). To that end, it will be necessary to maintain group stability, which can be very difficult in the context of healthcare were schedules and functions are largely impacted by external factors (Pilemalm & Timpka, 2008; Batalden et al., 2015). One subsidiary challenge is, for example, dealing with staff turnover; projects need to keep moving forward whilst not segregating newcomers. Moreover, relationships of trust are established between individuals; so, when people move jobs or retire, it can bring disruption or cause discontinuity to the process (Balka, 2013).

As noted by Batalden et al. (2015), another important external pressure – perhaps exclusive or more severe within healthcare projects – is how to conduct a situated process that accounts for customisation without disregarding established parameters of good standardised practice. These authors, then, highlight the urge for a keen

sensibility with regards to discerning necessary from unnecessary variation in practice and service outcomes (Batalden et al., 2015).

Internal to the PD Process

Participatory processes can be time consuming and resource-intensive (Simonsen &

Hertzum, 2012; Batalden-et al., 2015): projects are complex to plan and execute since they involve multiple stakeholders, often situated in different environments, and working under a variety of research and practice traditions. Within that setting, making the implicit knowledge of design explicit to non-designer partners (from other fields, such as healthcare), whilst embracing different traditions concerning decision-making, becomes fundamental to the sustainable future of PD (Gregory, 2009). Such process can

80 be made smoother by, for example, having designers working directly with healthcare staff, as an integral part of the structure of healthcare organisations and institutions²⁸. Design researchers often take a leading/central role and projects can be dependent on their involvement throughout the process (Bossen et al., 2014). In doing so, designers may end up ‘consciously or unconsciously monopolizing the process and subverting local norms in their choice of methods and modelling techniques’ (Winschiers-Theophilus et al., 2012). To avoid this, when designing in context with active

involvement of stakeholders, it is required that designers oscillate ‘between roles as facilitators, interventionists, observers and interpreters’ (Winschiers-Theophilus et al., 2012).

When design practice takes place within a transdisciplinary, healthcare context, research questions need to be generated at the grass-roots level, with participation of frontline staff (Balka, 2013), accounting for a representative perspective of all

professional groupings involved in the change processes. Furthermore – and this is particularly critical in the context of healthcare quality improvement – developing ways of assessing and evaluating the results of design interventions is key to establishing a productive rapport and exchange of ideas with other disciplines, researchers and practitioners. Dittrich et al. (2014) have argued that PD initiatives tend to follow the rationale of a research project and, thus, abide by standards and timelines that are better accepted by an academic readership interested in knowledge and theory, rather than a professional audience concerned with practical results. A large variety of possible approaches and methods combined with a loose rigour regarding documentation may play a role in making evaluation less comprehensible and

attractive to a non-designer public (Garde & van der Voort, 2012; Harder et al., 2013).

Hence, being open and clear about how, where, when and by whom projects are being conducted in healthcare environments will contribute to making frontline staff more aware and engaged (Bowen et al., 2013; Garde & van der Voort, 2014).

Acknowledging differences and building bridges between disciplines by, among other things, making different logic and methodologies transparent may help achieve common ground. Poggenpohl (2009b) states:

28 Examples of this can be seen in the Health Information Systems Programme (Gregory, 2009); and the ACTION for Health project (Balka, 2013), among others. Over a six-month period in 2009, the author of the current thesis has also worked as an in-house design consultant within the neonatal and paediatric departments of a regional hospital in the Midwest region of the USA. During that period, routine working relationships were established and sustained between the designer and a variety of healthcare

professionals, including nurses, doctors, managers and other non-clinical staff.

81 Perhaps two of the largest issues in developing common ground are sorting out and agreeing on the meaning of terms with different reference in various disciplines and negotiating a shared process […] Here, both an understanding of disciplinary roles and contributions come into play, to say nothing of epistemological differences and perceived power differences.

Related to Users

Designers need to help facilitate situations in which partnerships can flourish via developing processes, tools, and methods that enable complete and active participation in the full range of design activities (Robertson & Simonsen, 2012; Bowen et al., 2013).

Particularly in healthcare, sharing power and responsibility – over the process and outcomes – when involving multiple people from varied disciplines and backgrounds can be challenging (Gregory, 2009; Batalden et al., 2015). It entails recognising that the co-productive nature of healthcare services has consequences for the way roles and responsibilities are understood and enacted by stakeholders (Batalden et al., 2015). As experts in the ‘making of things’ designers can, thus, have a privileged discourse over discussions of a technical nature, particularly regarding implementation (Bratteteig &

Wagner, 2014). On the other hand, healthcare staff may overpower designers’ positions when it comes to issues of a more clinical nature. Finding the perfect balance between these two forms of ‘power domination’ constitute an important challenge for healthcare PD.

As well as having consequences for how hierarchy and decision-making are dealt with, sharing responsibilities in coproduction further includes consideration of issues related to intellectual property rights, and the unfolding revenue that could potentially come from the process and resulting technologies and innovations developed in

collaboration with users (Lee, 2008; Kyng, 2010).

At a more operational level, design activities that demand in-person commitment pose difficulties to busy staff (such as most working in the NHS). The extent to which satisfactory results can be obtained are often constrained by the available time, the number of people participating, and their relative understanding and use of the methods and tools required for the completion of activities (Kushniruk & Nøhr, 2016;

Jun et al., 2017). This means there is a constant need for the development of specific support that can tap into the potential and respond to the possibilities of busy, elusive participants, including investigating the limits and the potential application of new digital technologies (Gregory, 2009). Complementarily, it is critical to try and push the limits of the ‘scope of action’ of participants in a way they are able to recognise (Bowen

82 et al., 2010; Bratteteig & Wagner, 2014), as to make sure that, even in a

outcome-focused, regulated and highly-pressured environment such as healthcare, staff participation is not divorced from the core values of empowerment and democratisation.